Provider Demographics
NPI:1871571182
Name:MADER, RUSSELL DAVID (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:DAVID
Last Name:MADER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 W STONE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-2360
Mailing Address - Country:US
Mailing Address - Phone:423-246-4961
Mailing Address - Fax:423-245-3136
Practice Address - Street 1:2300 W STONE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-2360
Practice Address - Country:US
Practice Address - Phone:423-246-4961
Practice Address - Fax:423-245-3136
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000030476207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNGO5231Medicare UPIN
TN3824067Medicare PIN